Organic psychiatry

Question 1

Define delirium

Answer 1

An acute and transient state of global brain dysfunction with clouding of consciousness. The patient is not fully aware or ‘in touch’ with their environment. It is a sign that something is physically wrong.

Question 2

Name five risk factors for delirium

Answer 2

• Old age,
• Pre-existing physical or mental illness
• Substance misuse
• Malnutrition
• Polypharmacy

Question 3

In delirium, behavioural changes usually take one of two forms. What are these?

Answer 3

• Hyperactivity, agitation, agression

- Hypoactivity, lethargy, stupor, drowsiness and withdrawal

Question 4

How does the course of delirium differ to dementia?

Answer 4

-The course of delirium is short and fluctuates though out the day; whereas dementia is slowly progressive and lifelong.

Question 5

Name two medical causes of delirium

Answer 5

Anti-cholinergics and opiates

Question 6

What CNS pathology can cause delirium?

Answer 6

Raised ICP

Question 7

What metabolic pathology can cause delirium?

Answer 7

Liver failure, renal failure and electrolyte imbalance

Question 8

What are the infective causes of delirium?

Answer 8

Septicaemia, encephalitis, UTIs

Question 9

Name one nutritional cause of delirium

Answer 9

Thiamine deficiency i.e. Wernicke’s Encephalopathy

Question 10

What endocrine abnormality in diabetics can precipitate delirium?

Answer 10

Hypoglycaemia

Question 11

What is Huntington’s disease?

Answer 11

Huntington’s disease is an autosomal dominant disease characterised by chorea and dementia.

Question 12

What trinucleotide repeat causes Huntington’s?

Answer 12

A CAG repeat on the Huntington gene of chromosome 4.

Question 13

Prion diseases are rare disorders characterised by rapidly progressive neurological and psychiatric symptoms. What’s the main prion disease to affect humans?

Answer 13

Creutzfeldt-Jakob disease (CJD)

Question 14

What is the cause of variant CJD?

Answer 14

Eating BSE-infected beef. (BSE = Bovine spongiform encephalopathy)

Question 15

What’s the most common form of CJD?

Answer 15

Sporadic CJD. (The cause of this type is unknown).

Question 16

What is the main risk factor for Alzheimer’s disease?

Answer 16

Age

Question 17

What is the cause of familial early onset Alzheimer’s disease?

Answer 17

It is due to rare autosomal dominant gene mutations that cause an increase in beta-amyloid

Question 18

Name the genes on which mutations occur that can cause familial early onset dementia

Answer 18

Presenilin 1 gene
Presenilin 2 gene
Beta-amyloid precursor protein (APP) gene

Question 19

Which gene is associated with late onset Alzheimer’s disease? That is >65 yrs

Answer 19

Apo-lipo-protein E4 allele

Question 20

The cause of AD is multifactorial. What other factors play a role in development of Alzheimer’s?

Answer 20

Vascular risk factors such as hypertension, low IQ/poor educational level and head injury

Question 21

What are the four key pathological features of Alzheimer’s?

Answer 21

1) Cortical atrophy due to neuronal loss
2) Plaque formation
3) Intracellular neurofibrillary tangles
4) Cholinergic loss

Question 22

What are the NFTs made of in Alzheimer’s?

Answer 22

Abnomal (hyperphosphorylated) tau protein

Question 23

What four A’s describe the clinical presentation of Alzheimer’s disease?

Answer 23

Amnesia
Aphasia
Agnosia
Apraxia

Question 24

What is the word used to describe the inability to recognise faces?

Answer 24

Prosopagnosia

Question 25

What is the cause of vascular dementia?

Answer 25

Vascular dementia is due to infarcts caused by thrombo-emboli or arteriosclerosis

Question 26

What are the risk factors for vascular dementia (VD)?

Answer 26

They are the same as the risk factors for stroke e.g. older age, male gender, smoking, hypertension, diabetes, hypercholesterolaemia and atrial fibrillation.

Question 27

What are the three main features of pathology in VD?

Answer 27

Arteriosclerosis, cortical ischaemia and infarction

Question 28

How do you describe the clinical presentation of vascular dementia?

Answer 28

It has a step-wise progression

Question 29

What are Lewy bodies?

Answer 29

Lewy bodies are eosinophilic intracytoplasmic neuronal structures composed of alpha-synuclein with ubiquitin

Question 30

In Parkinson's disease, lewy bodies are found in the brainstem. Where are they found in addition to the brainstem in dementia with lewy bodies?

Answer 30

Cingulate gyrus and neocortex

Question 31

What symptoms should alert you to the possibility of dementia with lewy bodies?

Answer 31

- Fluctuating confusion with variations in levels of alertness - vivid visual hallucinations (often people and animals) - Spontaneous (new) parkinsonian signs

Question 32

Dementia with Lewy bodies can sometimes resemble delirium. Why is this dangerous?

Answer 32

Because prescription of antipsychotics can cause death due to neuroleptic sensitivity in lewy body dementia.

Question 33

Recurrent falls, syncope and autonomic instability is associated with which type of dementia?

Answer 33

Dementia with Lewy bodies

Question 34

What drugs can be used to slow the progression of Alzheimer's and Lewy body dementia? Give two examples

Answer 34

Acetylcholinesterase inhibitors (ACIs) e.g. Rivastigmine and Donepezil